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19255517888 Main Fax GETTLER RYAN INC 7:43 p.m. 04-23-2008 5112 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor, Stockton,California 95202 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> �-yy�� THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> �1TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> � <br /> Facility Name ARCO 5450 Phone# <br /> I <br /> L Address 1617 W FREMONT ST <br /> TCross Street 1-5 <br /> Y Owner/Operator BP West Coast ProdUCtS LLC Phone# <br /> C Contractor Name GETTLER-RYAN INC Phone# 925,551.7444 x150 <br /> O <br /> T Contractor Address 6747 SIERRA CT,SUITE J,DUBLIN,94568 CA Lic# 220793 Class A,13,C1011361 <br /> A Insurer STATE COMPENSATION INS FUND work Comp# 238-000358-2008 <br /> T ICC Technician's Certification Number 5300833-UT Expiration Date 12/28/2009 <br /> a ICC Installer's Certification Number 5300833-UI Expiration Date 12/28/2009 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved proved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A 120b <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH ARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FO HI HIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF A CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE O WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants I Titte AGENT FOR OWNER Date 2�J/0 <br /> 67 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME <br /> Liddy McKenzie TITLE Project Manacier PHONE# 925.551.7555 <br /> ADDRESS 6747 SIERRA CTo SUITE DUBLIN 94568 <br /> SIGNATURE L441 -zz:1_2 <br /> EH230038(revised 8/8l <br /> 1 <br />